Barefoot Business

Barefoot business
Maoist China pioneered the training of local peasants to
combat basic diseases - and the idea has inspired people all
over the world. But now the barefoot doctors are encouraged
to set up in business. Sheila Hillier finds out why.

On either side of the dusty road between Chengdu and Leshan, in rich and fertile Sichuan Province, the fields are now divided into thin strips, ribbons of bright green, each allotted to a household. This is the new responsibility system in practice, as are the wayside stalls in every village selling peaches, plums, watermelons and scarlet chillis, fresh and dried fish, chickens, ducks and slabs of newly-killed pig. But it is not the only change to be observed. At intervals of a dozen or so miles, small brick buildings sport a white signboard bearing a red cross, the sign of a rural private clinic.

Sichuan is a pioneering province - it's where the responsibility system was born. Now it has more private doctors than anywhere else in China1 and if its lead is followed again a market in health care could develop leaving poor peasants unable to pay for treatment and richer ones the prey of charlatans peddling expensive nostrums. China as a symbol of all that was rational and equitable in rural health care - exemplified by the barefoot doctor - might vanish. That at least is how it seems.

But China currently faces some important health problems which an unchanged system would not have been able to cope with. There aren't enough health services, particularly in the countryside. There is a shortage of health workers too, especially the highly trained and experienced ones. The population continues to expand, is growing older and becoming prey to chronic illnesses like cancer on a large scale. Although the number of babies who survive is high by Third World standards, babies in rural areas are up to four times as likely to die as those in towns.

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The present very partial answer to shortages is to allow a limited market in medical skills to develop, in the belief that newly-rich peasants can afford to pay. Growth and modernization of health services, rather than redistribution, is the aim. Hospitals have increased their fees so as to balance their budgets or even make a profit. 'It's ridiculous that an appendectomy costs the same as a pound of cucumbers,' said one official. 'People have the money to pay and we must see that they do.' All this seems a long way from the Sixties and early Seventies, when China's rural health policies caught the imagination of the world.

In the mid-Sixties many villages lacked even the most basic medical facilities. The nearest health centre might be an ill-equipped and poorly-staffed county hospital up to 40 miles or three days' walk away.

Sick peasants and their relatives would always bring their bedroll, knowing they might wait in a queue for a further day and night. Mao Zedong criticized the Ministry of Public Health for its alleged urban bias', calling it 'The Ministry of Urban Gentlemen's Health'.

So there was a switch in health policy to focus on the needs of the countryside. The most dramatic symbol of this change was the barefoot doctor - part peasant, part farm worker. After a brief or intermittent training barefoot doctors could attend to peasant health needs from snake-bite to appendicitis. For this they used a combination of Western and traditional remedies, many of the latter made from locally-grown herbs. By the early Seventies, there were just under two million barefoot doctors, roughly one per production team, each caring for about 40 families.2 And the whole thing was financed by a co-operative medical service into which each family paid a fixed sum - and the collective welfare fund matched it.

Why should such a system - apparently efficient, equitable, accessible and acceptable to the peasants - change in the 1980s? The truth was that, however ideal the concept, in practice the old rural health policy posed problems. The most obvious was the lack of skill of some barefoot doctors and the inability of brigades to pay for their further training. Inappropriate prescribing of dangerous drugs and incompetent surgery, combined with pressures to treat all cases rather than refer them upwards, often produced disastrous consequences which infuriated patients.

The sheer burden of work was also a difficulty - farm labour during the day plus visits to homes many miles away after dark meant that conscientious barefoot doctors - of which there were many - might have to surrender their income as a peasant in order to do their medical work properly. Small wonder that, when the responsibility system came in, many left to work in the fields and share in the new prosperity, reducing already depleted ranks. Co-operative payment systems began to decline by the late Seventies - and even villages that had them complained of debts.

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The truth was that the Maoists had set up a minimal system but were not prepared to invest in improving it. Since rural income remained static, the collective funds devoted to health care did too. So although basic health care was ensured there had been little development for ten years. Enter the believers in market forces, who said that since there were no incentives for improvement, it was no wonder things were in decline. They have proposed some novel solutions.

One is the official encouragement of private practice. Barefoot doctors, traditional doctors and retired hospital physicians have all been urged to set up clinics and pharmacies which they can run as small businesses3. Even practising doctors can see patients privately after work and it is hoped to tempt barefoot doctors back from the fields. Latest figures estimate that there are about 125,000 private doctors in China, about half being ex-barefoot doctors and traditional physicians. This is a small proportion of China's four and a half million medical workers but numbers jumped by 63 per cent in 1984 - 85.4 The rate of increase has now slowed to between six and seven per cent a year but the trend is likely to continue, for there is strong Government support.

A long-term decline in rural medical services may have been halted but there is no evidence that the quality of health care in China's 716,000 villages has improved or expanded as a result of the changes. Indeed it may have worsened for those who are poorer - there are cases of people avoiding or delaying seeking treatment if they have to pay directly. He Jianqing had her bladder damaged ten years ago when an incompetent barefoot doctor removed an IUD. Leaking urine caused her discomfort, but it wasn't serious enough for the village to pay for her operation. Now, her family can't afford hospital treatment either, so she buys medicines from the traditional doctor which help a little.

A system based on fee-for-service discourages preventive health care - why pay if you don't feel ill? It causes real hardship to the seriously ill who find hospital and medical bills mounting. Overcharging and swindling are also likely possibilities. Rather than producing more and better-distributed health services, direct payment to a private doctor means that doctors move towards those areas where fees will be higher and professional opportunities better.

Private development is also seen as an answer to the lack of hospital beds. Doctors are now offered time off work, with pay, to build their own hospitals and groups of rich peasants are encouraged to open hospitals as a sideline to boost their profits.

But the signs are that private development is not taking off as was hoped. Running hospitals is riskier than setting up a small factory, especially as it is not unusual for hospital staff to be beaten up if things go wrong. One hospital was besieged by the relatives of a dead patient who said she had been killed by doctors. They left her body uncollected for three days, then tried to force medical staff to join in a funeral procession. The hospital was closed for nine days because the staff were too frightened to come to work.

On balance the new health policies have not been particularly successful in increasing the volume of services, although the quality may have improved. Simply producing more hospitals does not in itself guarantee better medical care or better health. And by defining China's health problems as mainly 'lack of hospitals' planners may be promoting an expensive and inappropriate solution. Fee for service and the growth of private practice not only discriminates against the poor but makes medical care a response to effective demand rather than need. This might do something to bridge the rural-urban gap - but it will be replaced by inequalities between poorer and richer rural areas and peasants.

Besides, the new policies fail to recognize that China's greatest success has been in the field of preventive health. Much of this was carried out co-operatively by villagers who are now too busy tending their own fields. The majority of rural children, after 30 years of medical services, still suffer from rickets and worms - evidence that health depends as much, if not more, on better food and housing as on medicine. It is possible that current economic changes will improve things in the long term. But, for the present, the ambitious national policies have done little to improve the fledgling primary-health services which were Deng Xiaoping's inheritance.

Dr Sheila Hillier is Lecturer at the London Hospital Medical College and author of Health Care and Traditional Medicine in China 1800 - 1982.

The best source of regular and up-to-date information on China's changing social and political landscape is China Now magazine. This is a quarterly produced by the Society for Anglo-Chinese Understanding but is very accessible to an international readership. Annual subscriptions: UK and Ireland £5; elsewhere air mail £10, surface mail £7. From China Now, 152 Camden High Street, London NW1 0NE.

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